Expanding the pool of deceased organ donors: the ICU and beyond
Organ transplantation is a therapy that benefits thousands of patients every year. Its expansion is, however, limited by our chronic inability to meet the transplantation needs of patients. The World Health Organization (WHO) has called governments to progress towards self-sufficiency in transplantation, primarily by maximizing donation from the deceased. This requires adopting a whole hospital approach to identify areas of current medical practice that lead to the loss of donation potential, particularly in the management of patients with severe brain injuries who die despite initial active treatment, those with devastating brain injury (DBI)—defined as any neurological condition perceived as an immediate threat to life or incompatible with good functional recovery and where withdrawal or withholding of life-sustaining therapy is being considered—and those after unsuccessful cardiopulmonary resuscitation.
The primary duty of physicians is to preserve a patient’s life and to base their decisions not only on medical considerations but also on the values and preferences of their patients. When it is recognized that further active treatment is no longer in the best interests of a patient, the duties of professionals shift to palliation and end-of-life care which should also respect the same patient’s wishes and preferences whenever possible. Recognising this interpretation of best interests, critical care societies currently support the principle that organ donation should be offered as an option in end-of-life care [1, 2, 3, 4]. If the patient wished to donate their organs after their death, professionals should facilitate this whenever the circumstances of the patient’s death are consistent with organ donation.
Expanding the potential for both DBD and cDCD requires consensus on the determination of death by neurological and circulatory criteria incorporated into national guidance and increasing professional confidence and public acceptance of posthumous donation. DBD is the most common and preferred donation pathway. Nevertheless, high-quality management of severe brain injury is an essential prerequisite for both DBD and cDCD. Proper intensive care management not only increases the potential for patient recovery but also maintains donation potential when prompt identification of patients deteriorating to BD is followed by implementation of effective physiological support. After a decision is made to WLST because active treatment is no longer in the best interests of patients who do not meet BD criteria—and are unlikely to evolve to BD—then cDCD should be considered. The option of DBD and cDCD should be incorporated into guidelines for severe brain injury management removing any perception of conflict of interests by intensivists.
Whenever appropriate, BD should be declared and decisions to WLST made in accordance with national guidance, increasing public understanding and awareness that BD determination and decisions to WLST are made to reduce the burden of ongoing futile treatment and irrespective of any consideration or possibility of organ donation. Acceptance of this as medical best practice at the end-of-life may possibly decrease the number of family refusals to donation, a major issue in several countries.
An early decision to WLST in patients admitted to the ED with DBI, who are perceived at the time of admission to have a condition incompatible with survival or an acceptable functional outcome, is common in some countries. Recent guidance from professional bodies recommend delaying the WLST and admitting the patient to ICU primarily to allow a period of close clinical observation to improve the accuracy of prognostication, and better end-of-life care planning and delivery [5, 6]. These pathways may lead to an increase in organ donation as a secondary outcome, much as the introduction of post cardiac arrest pathways have done [8, 9]. The delay in the WLST can also lead to up to 30% of patients who were being considered for cDCD at this early stage to progress to BD and allow DBD .
The decision to withhold intensive care measures in patients being managed outside the ICU because they are not deemed clinically beneficial is also consistent with organ donation. The concept of intensive care to facilitate organ donation (ICOD) has been recently coined to refer to the initiation of life-sustaining therapies in patients with a DBI in whom the decision has been made not to apply any medical or surgical intervention on the grounds of futility, with the intention of incorporating organ donation into their end-of-life care plans [11, 12, 13]. ICOD may entail elective non-therapeutic ventilation, haemodynamic support and admission to the ICU to enable the neurological determination of death and DBD. Assessment of prognosis and of the likelihood that BD will occur shortly, appropriate communication with families and use of scarce ICU resources are some of the challenges associated with this practice. ICOD is a reality in several countries , and now accounts for more than 20% of deceased organ donors in Spain .
Deceased donation is also possible from persons who die following unsuccessful resuscitation from an in-hospital or out-of-hospital cardiac arrest. Uncontrolled DCD (uDCD) has the potential to significantly increase the donor pool  and is a practice supported by the 2015 European Resuscitation Council’s guidelines . However, uDCD remains unusual with the largest programs having been developed in Spain and France . The most important obstacles to the expansion of this type of donation are the absence of a legal framework supporting these programs, ethical concerns, lack of organizational capability and technical expertise, and doubts about the quality of organs retrieved from uDCD donors with an increased risk of primary non function.
In summary, opportunities to increase the donor pool exist in each of the scenarios mentioned above and can be adopted universally if the specific legal, ethical, professional and organizational considerations of every scenario are addressed in each country. Above all, what is needed is the continued engagement of the intensive and emergency care communities and an understanding of physicians’ responsibility to attempt to meet the transplantation needs of their citizens, by ensuring that their patients are always given the opportunity to donate their organs after their death when this is a possibility.
Compliance with ethical standards
Conflicts of interest
Alexander Manara is Regional Clinical Lead for Organ Donation for the South West of England. Beatriz Domínguez-Gil is Director General of the Organización Nacional de Trasplantes of Spain. The authors have no other conflict of interests to declare.
An approval by an ethics committee was not applicable.
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